INTRODUCTION:

Pregnancy and delivery pose major health hazards, especially for women with no pre-existing conditions. Approximately 15% of all expecting mothers have long-term or life-threatening problems, particularly during the third stage of labor. In India, a woman dies every five minutes as a result of these conditions. According to statistics from Karnataka, the majority of maternal fatalities occur during pregnancy (17%), during birth (28%), within 24hours after delivery (45%), and in the postpartum period (55%)¹.

Postpartum hemorrhage (PPH) affects 1% to 3% of all deliveries and is the primary cause of major complications and deaths in obstetrics globally, accounting for around 8% of maternal mortality in impoverished countries and 20% in developed ones. The United States has one of the highest rates of maternal death, at 11%, and it is rising, with 8 to 40 instances per 10,000 births. Major cause for PPH is atonic uterus and it accounts for 70% to 80% of all hemorrhage instances².

The occurrence fluctuates significantly; in affluent nations, it falls between 1 to 5%, whereas in low- and middle-income countries (LMICs), it can soar to as much as 10%. In rural regions, like those found in India, notably elevated figures are observed, as PPH impacts around 12% of births and escalates to 15% in later pregnancies³.

According to the Hindustan Times on December 30, 2024, Karnataka has recorded 217 maternal fatalities in four months, majority of cases notified in government hospitals and 38 cases detected in private clinics. Between 2019-2020, total of 662 maternal fatalities were reported, with the figure slightly raised to 714 in the following year. However, the numbers have since decreased, with 595 fatalities recorded in 2021-2022, 527 in 2022-2023, and 518 in 2023-2024. In 2024, there have been 348 fatalities among mothers in the state. The Maternal Mortality Ratio (MMR) for Karnataka during this period is calculated as 64 per one lakh live births, according to statistics obtained⁴.

Retained placenta occurs in 0.5 to 3% of women after childbirth and is a significant contributor to maternal mortality from postpartum hemorrhage; approximately 25% of maternal deaths in Africa are attributed to this issue. Additionally, around 15%-20% of maternal fatalities from postpartum hemorrhage are linked to retained placenta⁵. Uterine inversion is one of the most serious complications associated with childbirth. Even the inversion of uterus is rare, it carries a high risk of mortality due to hemorrhage and shock⁶. It occurs in approximately 1 in 3,500 to 1 in 20,000 childbirths. Typically, it happens within the first day after delivery⁷.

In India, the incidence of inversion notified as one in 2148 to one in 6407 births⁸. If not identified and treated appropriately, it could result in severe bleeding and shock, potentially leading to maternal death. The rate of maternal mortality could reach up to 15% annually⁹.

Postpartum hemorrhage can affect any individual after childbirth. Multiple risk factors for PPH exist, but 40% of cases arise in individuals without any identifiable risk factors. While healthcare providers may not be able to entirely prevent PPH, determining risk factors prior to delivery can help to decrease the likelihood of complications occurring during the third stage of labor¹⁰.

OBJECTIVES:

1. To assess the pre-test knowledge regarding third stage complications of labour among junior health assistant females.

2. To assess the post-test knowledge regarding third stage complications of labour among junior health assistant females.

3. To evaluate the effectiveness of structured teaching programme regarding third stage complications of labour among junior health assistant females.

4. To identify the association between pre-test knowledge regarding third stage complications of labour among junior health assistant females and selected demographic variables.

HYPOTHESES:

H01: There is no significant increase in the knowledge of the junior health assistant females regarding third stage complications of labour after the structured teaching programme than before structured teaching programme.

H02: There is no significant association between the level of knowledge and the selected demographic variables.

MATERIALS AND METHODS:

The research approach is Quantitative approach, the research design is Quasi experimental, one group pre-test and post-test design was used to assess the effectiveness of structured teaching programme on third stage complications of labour among junior health assistant females in selected maternity units, Bangalore. 40 junior health assistants were selected by simple random sampling technique. Self-administered questionnaire was used to collect the needed data. In view of the nature of the problem and to accomplish the objectives of the study, a structured teaching programme was prepared focusing on third stage complications of labour; a structured knowledge questionnaire was prepared to assess the effectiveness of structured teaching programme. Collected data was analyzed by using descriptive and inferential statistics.

In present study Mean pre-test level of knowledge was 16.85 with mean percentage of 42.1percentage with a SD of 3.9. Mean pre-test level of knowledge shows that majority of the samples (65%) fall in inadequate knowledge level.

In the post-test, significant increase in knowledge was found. Mean post-test level of knowledge was 31.7 with mean percentage of 79.3percentage with a SD of 2.6. Mean post-test level of knowledge shows that majority of the samples (62.5%) fall in adequate knowledge level.

Further, effectiveness of STP was tested by inferential statistics using the paired ‘t’ test. A significant difference 24.96(p<0.05) was found between pre and post-test knowledge scores of respondents indicating significant increase in knowledge after STP. Hence, null hypothesis H0¹ is rejected and STP was found to be effective in improving the knowledge of junior health assistant females.

RESULT:

The analysis of the data is organized and presented under the following headings:

Section-A: Frequency and percentage distribution of socio demographic variables.

Section-B: Level of knowledge on third stage complications of labour,

a) Overall pre-test knowledge of participants

b) Overall post-test knowledge of participants

Section-C: Comparison of aspect wise pre-test and post-test knowledge

Section-D: Effectiveness of structured teaching programme on third stage complications of labour.

Section-E: The association between knowledge scores and selected demographic variables.

Section-A:

Table-1 (a): Frequency and percentage distribution of selected socio demographic variables like age, marital status, years of experience, number of children, training programme. n=40

Characteristics	Category	Respondents
Characteristics	Category	Frequency (f)	Percent
1.Age (years)	31-40	14	35.0
	41-50	12	30.0
	51-60	14	35.0
2.Marital status	Unmarried	2	5.0
	Married	35	87.5
	Widow	3	7.5
3.Total Experience (years)	Below 10	13	32.5
	11-20	12	30.0
	21-30	15	37.5
4.Number of Children	No	6	15.0
	One	7	17.5
	Two	14	35.0
	Three and more	13	32.5
5.Have you undergone Training Programme	Yes	0	0.0
5.Have you undergone Training Programme	No	40	100.0

Table-1 (b): Frequency and percentage distribution of selected socio demographic variables like place of residence, type of family, total family income, previous source of information regarding third stage complications of labour. n=40

Characteristics	Category	Respondents
Characteristics	Category	Frequency(f)	Percent
6.Place of Residence	Rural	17	42.5
6.Place of Residence	Urban	23	57.5
7.Type of Family	Nuclear	16	40.0
	Joint	17	42.5
	Extended	7	17.5
8.Income/month	Rs.15,001-20,000	15	37.5
	Rs.20,001-25,000	12	30.0
	Rs.25,001-40,000	13	32.5
9.Previous Source of Information	Print media	10	25.0
	Electronic media	4	10.0
	Health professional	7	17.5
	Other	19	47.5

Section-B: (a) Overall Pre-test knowledge scores of respondents on third stage complications of labour.

The data in figure 1 reveals that among 40 participant’s majority 26(65.0percent) had inadequate knowledge and remaining 14 subjects (35.0 percent) had moderately adequate knowledge and none had adequate knowledge.

(b) Overall post-test knowledge scores of respondents on third stage complications of labour.

The data in figure 2 reveals that among 40 participant’s majority 25(62.5percent) had adequate knowledge and 15(37.5percent) had moderately adequate knowledge and none had inadequate knowledge.

Figure 1: Bar diagram representing pre-test knowledge scores.

Figure 2: Bar diagram representing post-test knowledge scores.

The data presented in table-2 reveals that the highest pre-test mean percentage in the aspect of general information was 60.8 with a SD of 0.8. The lowest pre-test mean percentage in the aspect of inversion of the uterus was 26.3 with a SD of 1.4. The highest post-test mean percentage in the aspect of general information was 87.1 with a SD of 0.7. The lowest post-test mean percentage in the aspect of inversion of the uterus was 76.8 with a SD of 1.1.

Section-D

Table-3: Effectiveness of structured teaching programme on third stage complications of labour. n=40

Knowledge assessment	Max. Score	Mean	Mean%	SD	Paired ‘t’ test
Pre test	40	16.85	42.1	3.9	24.96*
Post test	40	31.7	79.3	2.6	24.96*
Enhancement	40	14.85	37.1	3.8

* Significant at 5% level, t (0.05,39 df) = 1.96

The data in the table 4 illustrates that the post-test mean knowledge is 31.7, which is higher than the pre-test mean knowledge that is 16.85. The mean difference between pre-test and post-test score is 14.85.

The ‘t’ value was computed to determine the effectiveness of structured teaching programme on knowledge. The computed ‘t’ value (24.96) is found to be significant at 5% level. Hence the null hypothesis stating,

H₀₁: There is no significant increase in knowledge of junior health assistant females on third stage complications of labour after structured teaching programme than before structured teaching programme is rejected.

The difference of means observed is a true difference. Hence it can be calculated that the structured teaching programme has an influence in improving the knowledge of junior health assistant females on third stage complications of labour.

Section E: The association between demographic variables and pre-test knowledge score:

This section reveals that the obtained Chi-square values were 10.07, 8.19, 3.91, and 7.42. It shows that there was significant association between pre-test level of knowledge and selected demographic variables like age, number of children, residence, and type of family. But there was no significant association between the pre-test level of knowledge and selected demographic variables like marital status, years of experience, family income and previous source of information.

DISCUSSION:

The majority of the 40 respondent’s (35.0%) were in the age group of 31-40 years and 51-60 years. Majority of the respondents (87.5percentage) were married. Majority of the respondents (37.5percentage) were having experience of 21-30 years and (35.0percentage) of respondents had 2 children. All participants (100percentage) have not undergone any training programme. Majority (57.5percentage) were residing in urban area. The findings also revealed that (42.5percentage) of them were from nuclear family and majority (37.5percentage) were from income group of Rs. 15,001-20,000. Majority of respondents (47.5 percentage) had previous source of information from various sources regarding third stage complications of labour.

In pre-test knowledge on third stage complications of labour, the majority of the participants 65.0percent had inadequate knowledge and 35.0percent had moderately adequate knowledge and none had adequate knowledge.

A qualitative study was done to analyze trained birth attendants' knowledge, attitudes, and practices regarding the prevention, detection, and management of postpartum hemorrhage. The study included 23 trained birth attendants from 12 villages, together with their supervisors. The TBAs were aware of the necessity to promptly refer these women to a medical facility due to recognized concerns such blood loss and retained placenta. However, the TBAs were unaware about the risk factors for postpartum hemorrhage deaths in women and the reasons behind high blood loss. The study acknowledged that the TBAs were keen to learn more and that further training is essential¹¹.

In post-test knowledge on third stage complications of labour, the majority of the participants 62.5percent had adequate knowledge and 37.5percent had moderately adequate knowledge and none had inadequate knowledge.

A quasi experimental study was done in tertiary care hospitals to evaluate the effect of an educational intervention on knowledge and practice regarding uterine balloon tamponade as an intervention for severe PPH. 54 nurses were chosen to participate in the 8-week intervention, which included weekly training sessions. Results revealed significant improvements in both knowledge and practical application of UBT. In pre-test about 1.9% of nurses had adequate knowledge, which increased to 85.2% during post-intervention. Practical application of UBT improved to 100.0% during post-intervention. The study leads to the conclusion that educational interventions can improve maternal healthcare outcomes and greatly improve nurses' clinical abilities.¹².

The post-test mean knowledge is 31.7(79.3 percentage) was apparently higher than its pre-test mean knowledge that is, 16.85(42.1 percentage) suggesting that STP was effective in increasing the knowledge of JHAF’s regarding complications of third stage of labour. The mean difference between the pre-test and post-test knowledge score of junior health assistant females was found to be significant (t₍₃₉₎₌24.96) at 0.05 levels. This confirms that STP is an effective strategy. Hence the null hypothesis H₀₁was rejected.

A quantitative, pre-experimental research study was conducted in Jaipur, to assess the effectiveness of structure teaching programme on knowledge regarding preventive measures for PPH during intranatal period among staff nurses. A total of 60 staff were selected through convenient sampling technique. Structured knowledge questionnaire was used to collect pre and post-test knowledge. Result shows that in pre-test 71.67% staff nurses had moderate knowledge while 28.33% had adequate knowledge. The mean of knowledge was 17.87, mean% was 68.72 and SD was 3.17. The result of post test revealed that 83.33% staff nurses had adequate knowledge while 16.67% had moderate knowledge. The mean knowledge score was 23.12, with the mean percentage of 88.91 and SD was 2.29. Paired t test was used to assess the effectiveness of STP and the t test value was 16.43 at 0.05 level of significance. The association between post-test knowledge score and selected demographic variable revealed that there was no significant association between knowledge and demographic variables¹³.

There is significant association between pre-test level of knowledge and selected demographic variables like age, number of children, residence and type of family, but there was no significant association between the pre-test knowledge level with their selected demographic variables like marital status, years of experience, income of family and previous source of information.

RECOMMENDATIONS:

1. A similar type of study can be conducted in a larger population.

2. A comparative study can be done between the effects of structure teaching programme verses self-instructional module.

3. A study may be done to explore the attitude and practice of junior health assistant females regarding third stage complications of labour.

4. A study can be conducted with staff nurses who are working in maternity hospitals.

5. A comparative study can be conducted between staff nurses working in Govt. and private hospital.

6. Nurse led educational intervention programme can be conducted to the nurses to update their knowledge.

7. A comparative study can be conducted among JHAFs working in urban and rural PHCs.

8. A simulation based training programme on active management of third stage of labour to improve perinatal outcome can be conducted among novice nurses.

CONCLUSION:

Structured teaching programme was effective in improving the knowledge of junior health assistant females regarding third stage complications of labour. There is a significant difference between the pre-test and post-test knowledge. The study also suggests that improving the knowledge regarding third stage complications of labour among junior health assistant females is essential to reduce maternal mortality and morbidity.

CONFLICT OF INTEREST:

None.

ACKNOWLEDGMENTS:

I express my sincere appreciation and gratitude to our Principal Prof. Jolly Joseph, Guide, Co faculties and all those who helped us to complete this study peacefully.

REFERENCES:

1. Barbara Shane, Michele Burns. Preventing Postpartum Haemorrhage: Managing Third Stage of Labour. Maternal and neonatal health. September 2001; 19(3). Available from URL: http://www.reproline.jhu.edu.english.

2. Wormer KC, Jamil RT, Bryant SB. Postpartum Hemorrhage. [Updated 2024 Jul 19]. In: Stat Pearls Publishing; 2025 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499988.

3. Geller SE, Goudar SS, Adams MG, et al. Factors associated with acute postpartum hemorrhage in low-risk women delivering in rural India. Int J Gynaecol Obstet. 2008; 101(1):94–9.

4. https://www.hindustantimes.com/cities/bengaluru-news/karnataka

5. Grillo-Ardila CF, Ruiz-Parra AI, Gaitán HG, Rodriguez-Malagon N. Prostaglandins for management of retained placenta. Cochrane Database Syst Rev. 2014 May 16; 2014(5):CD010312. doi: 10.1002/14651858.CD010312. PMCID: PMC11055606.

6. Thakur M, Thakur A. Uterine Inversion. [Updated 2022 Nov 28]. In: Stat Pearls [Internet]. Treasure Island (FL): Stat Pearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525971/

7. Uterine inversion. https://my.clevelandclinic.org/health/diseases/22326-uterine-inversion

8. Zwart JJ, Richters JM, Ory F et al. Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nationwide population-based study. BJOG. 2008; 115:842–50

9. Owolabi AT, Dare FO. Risk factors for retained placenta, Nigeria. [Serial online] 2008 [cited on 2008 Jan]; 49(7): 532-537.

10. Available from: URL: http://www.smj.sma.org/4907.

11. Post-Partum Hemorrhage. https://my.clevelandclinic.org/health/diseases/22228-postpartum-hemorrhage

12. Bij de Vaate A, Coleman R, Manneh H, Walraven G. Knowledge, attitudes and practices of trained traditional birth attendants in the Gambia in the prevention, recognition and management of postpartum haemorrhage. Midwifery. 2002 Mar 1; 18(1):3-11.

13. Ara N, Khan HS, Sultania B. Educational Strategies for Enhancing Nurse Practices in Managing Severe Postpartum Hemorrhage: Evidence from A Peshawar-Based Intervention Study. The Research of Medical Science Review. 2025 Feb 3; 3(2):66-72.

14. Sharma JK, Sharma A. A study to assess the effectiveness of structured teaching programme on knowledge regarding preventive measures of postpartum haemorrhage during intranatal period among staff nurses working in selected Hospital Jaipur, Rajasthan. Asian Journal of Nursing Education and Research. 2024; 14(3):183-7. https://scholar.google.com/scholar

Received on 20.05.2025 Revised on 19.06.2025

Accepted on 09.07.2025 Published on 13.08.2025

Available online from August 20, 2025

Asian J. Nursing Education and Research. 2025;15(3):165-170.

DOI: 10.52711/2349-2996.2025.00034

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

S. No	Aspect wise knowledge	Pre test			Post test
S. No	Aspect wise knowledge	Mean	Mean%	SD	Mean	Mean%	SD
I	General Information	3.65	60.8	0.8	5.23	87.1	0.7
II	Postpartum Hemorrhage	8.50	42.5	2.4	15.43	77.1	1.6
III	Retained Placenta	2.08	51.9	1.0	3.38	84.4	0.7
IV	Inversion of the Uterus	2.63	26.3	1.4	7.68	76.8	1.1
	Knowledge score	16.85	42.1	3.9	31.7	79.3	2.6